Role of the surgeon as a variable in the treatment of rectal cancer

Increasingly, data are being accumulated on the influence of intersurgeon v ariability on outcome after curative surgical treatment of rectal carcinoma . Thus, today the individual surgeon has to be considered as an independent factor influencing locoregional recurrence, as well as survival rates. In general, higher local control and survival can be expected for specialized colorectal surgeons. There are no clear correlations between surgical volum e and outcome. Interinstitutional variability in treatment results reflects intersurgeon variability, but analysis is generally more difficult because of a lack of homogeneity with respect to different confounding factors. Th ere are several factors in surgical technique that are important for long-t erm outcome. Of greatest apparent importance is the adequacy of mesorectal excision (for carcinomas of the middle and lower third, total mesorectal ex cision; for carcinomas of the upper third, mesorectal, excision down to a m esorectal plane 5 cm distal to the gross tumor margin detected by the surge on in situ). Furthermore, intraoperative local tumor spillage (tumor perfor ation during mobilization, incision into the tumor), en bloc resection tech nique, skill, and the extent of regional lymphadenectomy may influence outc ome. For quality assurance, detailed operative reports are required, as wel l as histopathology examinations concerning indicators of surgical oncologi c quality discernable from the resection specimens. In future clinical tria ls of multimodal treatment of rectal cancer, quality assurance of surgery a nd pathology is necessary for consideration of the surgeon and surgical tec hnique prognostic factors. (C) 2000 Wiley-Liss, Inc.